Basic Information
| Provider Information | |||||||||
| NPI: | 1447842224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONOFRE IBARRA | ||||||||
| FirstName: | ELIAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11565 LAUREL CANYON BLVD UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913404168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183615030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1227 E LOS ANGELES AVE | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930652871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055624080 | ||||||||
| FaxNumber: | 8055796010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2021 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | AMFT123045 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.